Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Portagepointe during CMS and state inspections, most recent first.
The facility did not ensure that the Kitchen Manager, who had not completed the Certified Dietary Manager (CDM) exam, was properly qualified to perform resident nutritional assessments. Despite completing the coursework, the Kitchen Manager had not taken the certification exam and was carrying out key dietary responsibilities without the required credentials, affecting all residents.
Surveyors observed multiple instances of expired and unlabeled food products in several kitchen areas, as well as improper use and inadequate sanitization temperatures in the high-temperature dish machine. The Kitchen Manager confirmed that food items were not consistently labeled or discarded as required, and staff continued to use a malfunctioning dish machine that did not reach the necessary sanitizing temperature.
Surveyors found that food items brought in by visitors, such as a pickle jar and health shakes, were stored in the refrigerator without required labels indicating the resident's name or date of entry. The facility's policy mandates labeling and timely disposal of such items, but these procedures were not followed, resulting in unmarked and potentially outdated food being stored.
A resident with severe cognitive impairment and a history of UTIs had a Foley catheter inserted by an RN without obtaining a physician's order or notifying the responsible party. The DON confirmed there was no appropriate diagnosis for catheter use, and facility policy requiring provider orders and diagnosis confirmation was not followed.
A fire alarm pull station was observed to be blocked in the Delaware dining room near the courtyard doors, making it inaccessible and in violation of NFPA 101 requirements for manual fire alarm system initiation. This was confirmed by the Facilities Director during the inspection.
Surveyors found that shower curtains in multiple resident rooms were within 18 inches of sprinkler heads, violating NFPA 13 requirements, and also noted missing ceiling tiles in two utility areas. These issues were confirmed by the Facilities Director.
A section of the Delaware dining room was used as a temporary food storage and preparation area, containing refrigerator/freezer units and combustible boxes, and was separated from the corridor by portable dividers that did not meet egress requirements, violating NFPA 101 standards.
Surveyors observed a fan in an office area powered by an extension cord connected to another extension cord, a setup confirmed by facility leadership. This arrangement does not comply with NFPA 70 requirements, which prohibit using extension cords as a substitute for permanent wiring, and could affect two occupants in the event of an electrical issue.
The facility failed to ensure timely physician response to MRR recommendations for two residents. One resident had a GDR recommendation delayed by two months, and another had recommendations for GDR and anticoagulation therapy review delayed by two and three months, respectively. The facility lacked a formal policy for MRR or timeframes for physician response.
The facility failed to address multiple food safety and sanitation deficiencies, including improper sanitizing of the dish machine, lack of air gaps in kitchen sinks, outdated food, contamination of food trays, improper testing of sanitizing solutions, and improper stowing of soiled dishes. Staff interviews revealed a lack of knowledge regarding food expiration dates and sanitizing procedures, potentially exposing residents to foodborne illnesses.
The facility failed to provide a safe, functional, and sanitary environment in the kitchen facilities, lacking commercial-grade equipment, proper sinks, and adequate space for food preparation and dishwashing. Interviews with staff confirmed ongoing issues, including malfunctioning ovens, leaking dish machines, and inappropriate practices for handling wet dishes.
A resident with diabetes and other medical conditions experienced a significant delay in blood glucose monitoring and glucagon administration after being found lethargic and unresponsive. The delay was due to the unavailability of emergency glucagon in the resident's hall and the nursing staff's lack of awareness of its location. The Nursing Home Administrator acknowledged the concern.
Unqualified Dietary Manager Performing Nutritional Assessments
Penalty
Summary
The facility failed to ensure that the dietary department was staffed with sufficient and properly trained personnel to fulfill the functions and duties of nutritional services. Specifically, the Kitchen Manager had not completed the Certified Dietary Manager (CDM) exam, despite being in the position for over a year. Although the Kitchen Manager had finished the required coursework, he had not yet scheduled or taken the certification exam and was performing resident nutritional assessments without this qualification. This deficiency was identified through interview and record review, and it was confirmed that the Kitchen Manager was responsible for key dietary functions without the necessary certification. The report references the FDA Food Code 2017, which requires that the person in charge demonstrate knowledge and proficiency through certification, highlighting that the facility did not meet these regulatory requirements for all 56 residents potentially affected.
Deficient Food Storage, Labeling, and Dish Machine Sanitization
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During the initial kitchen tour, surveyors observed multiple instances of expired food and food products that were not properly labeled or dated across several kitchen areas, including [NAME] House, Delaware House, Bath House, Wiona House, and Medora. Specifically, there were 13 expired foods in three refrigerators in one area, four expired foods and three potentially hazardous foods (PHF) not labeled with an open date in another, and additional expired or unlabeled foods in other locations. The Kitchen Manager confirmed that all opened food products should be labeled with a use-by date and expired items should be discarded, in accordance with FDA Food Code requirements. Additionally, the facility failed to ensure that high-temperature dish machines were routinely tested for proper sanitizing of food contact surfaces. Observations revealed that the high-temperature dishwasher in the Pewabic Kitchen did not reach the required sanitizing temperature, with final rinse temperatures recorded at 137°F and 117°F, both below the FDA-required 160°F. The sanitization strip used did not indicate proper sanitization, and staff were observed using the malfunctioning dish machine, including manually holding the door shut and using a towel to collect leaking water. These practices did not meet professional standards for food safety and sanitation.
Failure to Label and Monitor Food Brought in by Visitors
Penalty
Summary
During a kitchen tour, surveyors observed that food items brought in by visitors for residents, including a glass pickle jar and two health shakes, were stored in the facility refrigerator without any labels indicating the resident's name or the date the items were brought in. The Kitchen Manager confirmed that facility policy requires all such items to be labeled with the resident's name and date of entry. Review of the facility's policy further specified that perishable food from outside sources should be labeled and stored in the refrigerator, and prepared food items should be discarded within 72 hours if not consumed. The failure to label and monitor these items resulted in unmarked and potentially outdated food being present in the refrigerator units used by residents.
Foley Catheter Inserted Without Physician Order or Notification
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infections, Alzheimer's disease, dementia, and anxiety disorder was found to have a Foley catheter inserted without a physician's order or appropriate diagnosis. The resident's cognitive skills were severely impaired, and the responsible party was not notified prior to the catheter insertion. The family member expressed concern upon learning about the catheter placement, stating that she had not been contacted for permission. The Director of Nursing confirmed that the physician was not called to obtain an order for the catheter, and acknowledged that there was no diagnosis justifying its use. The registered nurse who inserted the catheter reported making the decision independently due to the resident seeping urine, without consulting the physician or notifying the responsible party. Facility policy requires confirmation of a provider's order and an appropriate diagnosis before catheter insertion, which was not followed in this instance.
Blocked Fire Alarm Pull Station in Dining Room
Penalty
Summary
A deficiency was identified when a fire alarm pull station was found to be blocked in the Delaware dining room near the courtyard doors. This arrangement violates the requirements for manual initiation of the fire alarm system as specified by NFPA 101, 9.6.2.7, which mandates that manual alarm boxes must be visible and continuously accessible. The observation was made during a facility inspection and was confirmed by the Facilities Director at the time of the survey. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K342: Fire Alarm System Initiation The facility will ensure manual initiation of the fire alarm system is arranged as required. This will be accomplished with the following:
Sprinkler System Obstructions and Missing Ceiling Tiles
Penalty
Summary
The facility failed to maintain compliance with NFPA 13 standards for automatic sprinkler system installation and maintenance. During an inspection, surveyors observed that multiple resident room shower curtains were positioned within 18 inches of the sprinkler head spray pattern, which is not permitted under NFPA 13, section 8.5.5.2. Additionally, ceiling tiles were found to be missing in the Pewabic House Pantry and the Franklin House Clean Utility rooms. These deficiencies were confirmed by the Facilities Director at the time of discovery. No specific information about individual residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K351: Sprinkler System Installation The facility will ensure the sprinkler system is installed as required. This will be accomplished with the following: The facility will inventory all shower curtains in the facility and replace the shower curtains that are within 18" of the sprinkler head spray pattern. The facility will visually inspect each shower curtain in the facility to identify any that are not compliant, and these will be replaced. The facility will work with the Materials Management department to ensure that the appropriate shower curtains are stocked in the supply room so that when a curtain needs to be replaced, it is replaced with a compliant curtain. The facility will ensure all ceiling tiles are in place in two locations: Pewabic house pantry and Franklin clean utility room. This will be accomplished by replacing all missing ceiling tiles in these locations. The facility will conduct a weekly audit to look for missing ceiling tiles throughout the entire facility. If a missing ceiling tile is identified, the NHA will submit a work order to the Facilities department to have the ceiling tile replaced or reinstalled that day. All staff will be provided education that all ceiling tiles need to be in place at all times unless being actively worked on. All staff will sign off on this education. If staff notice a ceiling tile is missing, a work order needs to be submitted to the Facilities department to have the tile replaced or reinstalled that day.
Improper Storage and Egress in Dining Room Area
Penalty
Summary
A portion of the Delaware dining room was observed to have been converted into a temporary storage area for food preparation and storage, which included the use of three refrigerator/freezer units and the storage of multiple combustible boxes. This area, open to the corridor, did not meet the provisions required by NFPA 101, 19.3.6.1(1)(a), as it was separated from the rest of the unit only by portable cubicle dividers. These dividers failed to maintain the necessary egress requirements as specified by NFPA 101, 19.3.6.1(7)(c). The deficiency was confirmed by the Facilities Director during the surveyor's observation.
Plan Of Correction
K361: Corridors - Areas Open to Corridor The facility will ensure spaces open to corridors meet all provisions as required. This will be accomplished by the following: • The facility will remove dry storage including combustible boxes located in the temporary kitchen area. These items will be moved to the Franklin clean utility room and/or the Medora pantry, until the new commercial kitchen is completed. Expected completion date for new commercial kitchen is 7.4.25. • The facility will audit the temporary kitchen space daily to ensure that combustibles remain removed from the temporary kitchen area. Audits will be done until the time the new commercial kitchen is completed, expected completion date 7.4.25. • No other residents affected, as we only have one temporary kitchen set up. • Commercial kitchen completion is expected 7.4.25. The temporary kitchen will be taken down and moved to the new kitchen. Once the new kitchen is in place, there will no longer be an issue.
Improper Use of Extension Cords for Electrical Equipment
Penalty
Summary
A deficiency was identified when, during an observation in the Wynona Den Office, a fan was found plugged into an extension cord, which was then plugged into another extension cord to supply power. This setup was confirmed by both the Facilities Director and the Administrator at the time of discovery. The use of extension cords in this manner does not comply with NFPA 70, section 400.8, which prohibits the use of extension cords as a substitute for permanent wiring. The report notes that this practice could affect two occupants in the event of an electrical overload or short circuit.
Plan Of Correction
K920: Electrical Equipment - Power cords and Extension cords The facility will ensure that power strips are in compliance with code and that extension cords are not used. This will be accomplished by: The facility will work with the Facilities department to have an additional electrical outlet installed in the wall. The facility will educate all staff that extension cords are not to be used and that power strips need to meet code requirements. All staff will sign off on this education. The facility will work with the staff member who uses this office to educate them that extension cord use is prohibited, and this staff member will sign an attestation of understanding that they will not use inappropriate power strips or extension cords. This employee's office will be audited weekly for 3 months to ensure compliance.
Failure to Ensure Timely Physician Response to MRR Recommendations
Penalty
Summary
The facility failed to ensure timely physician response to Medication Regimen Review (MRR) pharmacy recommendations for two residents. Resident #19, who has diagnoses including progressive neurological conditions, heart failure, hypertension, multiple sclerosis, anxiety, chronic pain, and depression, had a recommendation for a Gradual Dose Reduction (GDR) of psychotropic medications made by the pharmacist in January 2024. However, the physician did not sign the MRR until March 2024. The facility did not have a policy for MRR or timeframes for physician response, as acknowledged by the Nursing Home Administrator (NHA) and Director of Nursing (DON). The Drug Regimen Review Procedure provided by the pharmacist was not formally adopted by the facility. Resident #52, with diagnoses including non-traumatic brain dysfunction, diabetes mellitus, Alzheimer's disease, and other conditions, had a recommendation for a GDR of psychotropic medications made in September 2023, which the physician declined approximately two months later. Another recommendation for periodic review of anticoagulation therapy made in December 2023 was signed by the physician in March 2024. The physician could not explain the delays, suggesting that documents sent to his office might have caused the delay. The NHA stated that a one-month timeframe would be considered timely for physician response, but the facility lacked a formal policy to enforce this.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to identify and implement corrective actions in response to multiple deficiencies related to food safety and sanitation. Observations revealed that the mechanical dish machine did not demonstrate proper sanitizing, and there were improper air gaps in the kitchen sinks, which could lead to backflow of contaminated wastewater. Additionally, outdated time/temperature-controlled food was found accessible for use, and food trays prepared for meal service were observed to be contaminated by water splashing from a nearby hand sink. The facility also failed to demonstrate proper testing of the sanitizing solution used for meal preparation countertops, as the testing was conducted outside the acceptable temperature range for accuracy. Furthermore, soiled dishes and utensils were improperly stowed, making them accessible to residents and guests, which is against professional standards for food service safety. Interviews with kitchen staff revealed a lack of knowledge regarding the expiration dates of food products and the proper use of sanitizing test strips. The kitchen manager and cooks were unaware of how to read the dating system on food containers and the temperature restrictions for the sanitizing solution test strips. These deficiencies potentially exposed all 59 residents to foodborne illnesses due to improper food handling and sanitation practices. The facility did not have a system in place to address these issues, leading to the observed deficiencies.
Inadequate and Dysfunctional Kitchen Facilities
Penalty
Summary
The facility failed to provide an environment that was safe, functional, and sanitary for residents, staff, and visitors, specifically in the kitchen facilities used for food storage, preparation, and delivery. The main preparation kitchen, originally designed as a household kitchen, was inadequate and lacked commercial-grade equipment, including ovens, refrigeration units, and appropriate storage space. The kitchen also had a small three-compartment sink with waste lines directly connected to the sanitary sewer lines, lacking required air gaps, and compartments too small for large baking and cooking dishes. Additionally, the kitchen did not have a food preparation sink, and the under-the-counter dish machine waste line was improperly installed. Countertops were replaced with non-commercial plastic laminate, and the kitchen lacked a designated housekeeping closet for cleaning supplies and equipment. The dining room kitchen, also used for cooking, had inadequate space for soiled dishes and was observed to have discolored, stained, and pitted sinks, leaking dish machines, and temporary fabric barriers reducing usable dining space. Wet dishes were placed on wheeled carts over carpeted areas, making them difficult to clean properly. The interior of the sink base cabinet was deteriorating and in poor condition. Interviews with kitchen staff and the Nursing Home Administrator confirmed the ongoing issues with the kitchen facilities. Cook C reported that the ovens did not always work correctly, making it difficult to heat food properly, and there was not enough space to store soiled dishes. The small under-counter dish machine leaked water onto the floor regularly, and staff had to wash all cooking equipment and residents' soiled dishes in the machine. There was no acceptable location to place racks of wet dishes after being removed from the dish machine, leading to inappropriate practices such as placing wet trays on wheeled carts behind a temporary wall over carpeting. The Nursing Home Administrator confirmed that the facility had agreed to commence construction of new kitchen facilities following the previous year's survey, but no contracts had been signed, and no construction had begun to address the identified issues.
Delay in Blood Glucose Monitoring and Glucagon Administration
Penalty
Summary
The facility failed to ensure timely monitoring of blood glucose and administration of glucagon for a resident (R59) who was prescribed insulin and other blood glucose-lowering medications. The resident, who had a history of stroke, end-stage renal disease, diabetes mellitus, and hemiplegia, was found lethargic and less responsive. Despite the facility's hypoglycemic protocol, which required immediate blood glucose assessment and administration of glucagon for severe hypoglycemia, there was a significant delay in both actions. The resident's blood glucose was not checked until 54 minutes after being found unresponsive, and glucagon was administered only after this delay, resulting in a prolonged period of severe hypoglycemia for the resident. The resident's blood glucose levels were critically low at 23 mg/dL when first assessed, and multiple glucagon injections were required to stabilize the levels. The delay in treatment was attributed to the unavailability of emergency glucagon in the resident's hall and the nursing staff's lack of awareness of its location. Interviews with the nursing staff and the Director of Nursing (DON) revealed that emergency glucagon was not readily available in all facility halls, and the staff was not adequately informed about its storage locations. The Nursing Home Administrator (NHA) acknowledged the concern and agreed that the delay in assessment and administration of glucagon was problematic. The NHA expected glucagon to be administered within 10 minutes of finding a diabetic resident lethargic and unresponsive.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hancock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Point Nursing & Physical Rehabilitation Ce | 0.4 mi | ★★★★★ | 0 | 0 |
| Canal View - Houghton County | 1.1 mi | ★★★★★ | 12 | 0 |
| Greentree Of Hubbell Rehabilitation And Health | 7.9 mi | ★★★★★ | 42 | 0 |
| Bayside Village | 26.8 mi | ★★★★★ | 22 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.